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. 2019 Feb;39(2):402-413.
doi: 10.1111/risa.13214. Epub 2018 Oct 8.

Modeling Undetected Live Poliovirus Circulation After Apparent Interruption of Transmission: Pakistan and Afghanistan

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Modeling Undetected Live Poliovirus Circulation After Apparent Interruption of Transmission: Pakistan and Afghanistan

Dominika A Kalkowska et al. Risk Anal. 2019 Feb.

Abstract

Since most poliovirus infections occur with no paralytic symptoms, the possibility of silent circulation complicates the confirmation of the end of poliovirus transmission. Based on empirical field experience and theoretical modeling results, the Global Polio Eradication Initiative identified three years without observing paralytic cases from wild polioviruses with good acute flaccid paralysis surveillance as an indication of sufficient confidence that poliovirus circulation stopped. The complexities of real populations and the imperfect nature of real surveillance systems subsequently demonstrated the importance of specific modeling for areas at high risk of undetected circulation, resulting in varying periods of time required to obtain the same level of confidence about no undetected circulation. Using a poliovirus transmission model that accounts for variability in transmissibility and neurovirulence for different poliovirus serotypes and characterizes country-specific factors (e.g., vaccination and surveillance activities, demographics) related to wild and vaccine-derived poliovirus transmission in Pakistan and Afghanistan, we consider the probability of undetected poliovirus circulation for those countries once apparent die-out occurs (i.e., in the absence of any epidemiological signals). We find that gaps in poliovirus surveillance or reaching elimination with borderline sufficient population immunity could significantly increase the time to reach high confidence about interruption of live poliovirus transmission, such that the path taken to achieve and maintain poliovirus elimination matters. Pakistan and Afghanistan will need to sustain high-quality surveillance for polioviruses after apparent interruption of transmission and recognize that as efforts to identify cases or circulating live polioviruses decrease, the risks of undetected circulation increase and significantly delay the global polio endgame.

Keywords: Disease eradication; disease outbreaks; disease surveillance; environmental surveillance; infection transmission modeling; poliomyelitis; poliovirus; vaccination.

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Figures

Figure 1
Figure 1
Confidence about no circulation in Pakistan and Afghanistan as a function of the detected-event free period assuming perfect AFP surveillance without ES, and lines provided to indicate 95% and 99% for reference.
Figure 2
Figure 2
Confidence about no circulation in Pakistan and Afghanistan as a function of the detected-event free period assuming different estimates of ES, with perfect AFP surveillance without ES, and lines provided to indicate 95% and 99% for reference. Abbreviations: AFP, acute flaccid paralysis; DEFP, detected-event-free period; ES, environmental surveillance; GS, general population sites distribution; IP, isolation-rate based prevalence; NS, national sites distribution; PP, proportional prevalence; SS, site-specific; SW, system-wide; US, under-vaccinated subpopulation sites distribution
Figure 2
Figure 2
Confidence about no circulation in Pakistan and Afghanistan as a function of the detected-event free period assuming different estimates of ES, with perfect AFP surveillance without ES, and lines provided to indicate 95% and 99% for reference. Abbreviations: AFP, acute flaccid paralysis; DEFP, detected-event-free period; ES, environmental surveillance; GS, general population sites distribution; IP, isolation-rate based prevalence; NS, national sites distribution; PP, proportional prevalence; SS, site-specific; SW, system-wide; US, under-vaccinated subpopulation sites distribution
Figure 3
Figure 3
Confidence about no circulation in Pakistan and Afghanistan as a function of the detected-event free period assuming different estimates of less than perfect AFP surveillance, with perfect AFP surveillance without ES, and lines provided to indicate 95% and 99% for reference.
Figure 3
Figure 3
Confidence about no circulation in Pakistan and Afghanistan as a function of the detected-event free period assuming different estimates of less than perfect AFP surveillance, with perfect AFP surveillance without ES, and lines provided to indicate 95% and 99% for reference.
Figure 4
Figure 4
Confidence about no circulation in Pakistan and Afghanistan as a function of the detected-event free period assuming a range of less than perfect AFP surveillance and a range of ES, with perfect AFP surveillance without ES, and lines provided to indicate 95% and 99% for reference
Figure 4
Figure 4
Confidence about no circulation in Pakistan and Afghanistan as a function of the detected-event free period assuming a range of less than perfect AFP surveillance and a range of ES, with perfect AFP surveillance without ES, and lines provided to indicate 95% and 99% for reference

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